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NavMed 369 


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Rear Admiral Bartholomew W. Hogan MC USN - Surgeon General 
Captain Donald R. Childs MC USN - Editor 

Vol. 34 

Friday, 18 September 1959 

No. 6 



Systemic Causes of Abdominal Pain, Part II 

Meckel's Diverticulum at a Children's Hospital , 


Results of Treatment of Malignant Melanoma , 

Paget 's Disease 

Vitamin B 12 and Folic Acid in Medical Practice 

Tired Mother Syndrome 


Vaccinia Immune Globulin (BuMed Inst. 6230. 10) 

Letters of Congratulation 

From the Notebook 


Tranquilizing Drugs in Oral Surgery 

Navy Exhibits at A. D. A. Session ' 

Anniversary Greeting 

Philippine Armed Forces Dental Service Anniversary , 

Continuous T raining Program 

Federation Dentaire Internationale , t 

Dental Spaces in Vessels (BuMed Inst. 6700. 5B) 


Change in Active Duty Policy for Enlistees 

Hospital Corps Division Activated 

Tables of Organization (BuPers Inst. 5400. IH) 


Respiratory Virus Diseases 28 Food Establishment Sanitation. 

Penicillin Resistance in Gonococci 32 Salmonella Blockley Outbreak 
Calcium Hypochlorite 39 







Medical News Letter, Vol 34, No. 6 

Systemic Causes of Abdominal Pain. 
Part II 

N : arological Diseases. Ma.iy neurological lesions in or near the 
abdomen cause localized pain and masquerade as intraperitoneal disease — 

mic or functional- Lesions affecting one or more of the spinal nerve roots 
often are overlooked when presenting abdominal pain since both patient and 
physician are accustomed to consider abdominal pain as being abdominal in 
origin. However, accurate localization of the lesion is usually possible. 

Oiher neurological diseases cannot be localized to c ... spinal segment. 
Perhaps the most notorious example is tabes dorsalis in which the gastric 
crisis imitates an acute surgical abdomen. This clinical picture is tot con- 
fine H to tabes alone, as a similar crisis may occur in pati its with diabetic 
leuropathy — pseudotabes diabeticum 

Migraine headaches and ' vascular ' headaches similar to migraine often 
are accompanied by nausea and occasionally by vomiting. In this instance, 
it is important to remember that abdominal discomfort and nausea invariably 
associated with headache probably are not the result of intra-abdominal disease 
Abdominal migraine 1 is difficult to diagnose with any surety, the differentiation 
between it and other functional abdominal pains, such as pylorospasm and 
"spastic colon, ' being obscure. 

Similar difficulties beset the diagnosis of abdominal epilepsy, a condition 
which actually occurs much less frequently than it is diagnosed. The diagnosis 
rests upon a specific series of signs and symptoms and a demonstration' of a 
profound amelioration or disappearance of the attacks upon institution of ade- 
quate anticonvulsive therapy. Abdominal epilepsy and related types of abdom- 
inal pain originating in the brain can be ''idiopathic' or due to various discover- 
able lesions — cerebral trauma, brain tumors, tuberous sclerosis, infectious 
and toxic encephalopathies, and familial degenerative diseases of the central 
nervous system . 

Many diseases of the brain, particularly acute necrotizing or inflamma- 
tory conditions, such as apoplexy or bulbar poliomyelitis, may cause acute 
ulceration of the stomach or jejunum. In addition, neurological disorders of 
the brain and spinal cord that produce bowel difficulties due to weakness oT the 
abdominal wall or to deficit in the nerve supply of the viscera may cause abdom- 
inal pain due to fecal impaction or diarrhea. 

Glaucoma, while not ordinarily considered a neurological disease, prob- 
ably produces abdominal symptoms through reflex nervous pathways. Nausea 
and vomiting are common in the acute 'congestive' form and it uncommonly 
happens that the patient, in his desperation and misery fails to notice the blind- 
ness and only complains of 'stomach ache. ' 

A common abdominal or near -abdominal pain of unknown cause, proctalgia 
fugax, is mentioned because it more closely resembles a neuralgia than it does 
any other disease. This is a paroxysm of excruciating pain referred to a point 

Medical News Letter, Vol. 34, No. 6 

in the rectum an inch or more above the anus. The attacks last only a few 
minutes and appear so infrequently that no therapy is necessary or available 
in time. It occurs more often in men than in women and more frequently in 
sexually frustrated persons. 

Hematological Diseases . In a number of diseases involving hemato- 
poiesis or blood destruction, unexplained abdominal distress may be a pre- 
senting complaint. Such diseases are leukemia, hemolytic anemias of various 
kinds, transfusion reactions, myelophthisic anemias, polycythemia vera, 
hemophilia or other coagulation defects, and multiple myeloma. In many of 
these situations abdominal pain is due to a complication, such as uric acid, 
kidney stones, peptic ulcer, or splenic infarcts in polycythemia; hemorrhage 
into the retroperitoneal structures, mesocolon, peritoneal cavity, or bowel 
wall in hemophilia bone destruction in multiple myeloma and deep bone pain 
in leukemia Mild abdominal distress has been reported in pernicious anemia, 
irpn deficiency anemias, and aplastic anemias. 

In sickle cell disease, abdominal crises are particularly apt to be severe. 
In some hybrid types the dramatic intensity of the pain may be out of all propor- 
tion to the quantity of hemolysis. Jaundice may be absent and anemia negligible. 

The whole problem of abdominal pain in hemolytic anemias is complicated 
by the greater tendency of such patients to develop hepatic dysfunction and gall- 

Mechanical and Physical Trauma . Any severe injury — from a broken leg 
to a scalded hand — is very likely to interfere with normal muscular movements 
of the gastrointestinal tract, resulting in a wide range of symptoms from nau- 
sea and vomiting to severe pain occurring with paralytic ileus. Acute gastric 
dilatation may give rise to mild to severe upper abdominal pain, bloating, or 
nausea; or sudden development of profuse sweating, tachypnea, anxiety, tachy- 
cardia, pallor, low blood pressure, and other signs of shock, with progression 
to death. 

Motion sickness occasionally evokes the complaint of a 'stomach ache' 
which may be more the result of physical inactivity or prolonged maintenance 
of a supine position than the immediate effect of reaction to motion itself. 

Radiation sickness ordinarily produces nausea, but not abdominal pain. 
However, the condition may be associated wlith discomfort if food has been 
eaten and retained despite nausea. Radar equipment can, like diathermy 
apparatus, inflict visceral or subcutaneous burns. If peritoneal structures 
are involved, the pain may be anything from an ''intense heat" to ordinary types 
of abdominal pain arising from visceral inflammation. Ultrasound involves 
similar hazards. 

Severe cramping or vise-like pains, usually abdominal and often in the 
back and limbs as well, sometimes are produced when bubbles of gas are lib- 
erated into the blood stream. This occurs in instances of rapid reduction in 
atmospheric pressure either in sudden return to normal from increased pres- 
sure, or rapid ascent to low barometric pressure in flying — 'bends, " Caisson 
disease-, " or flyer's bends. 

Medical News Letter, Vol. 34, No. 6 

P sychiatr ic Di s or de r s . A great variety of abdominal pains may arise 
from emotionally-produced disordered motor function of the gastrointestinal 
tract. Among the types are: functional cardiospasm or pylorospasm; peri- 
umbilical cramps with rapid motility of the small intestine; bloating discom- 
fort, painful constipation, or colicky diarrhea due to emotional influences 
upon the colon and sharp left upper quadrant pain aggravated by breathing 
and sometimes simulating angina pectoris when a gas -filled splenic flexure 
presses upon the diaphragm Anxiety, fear, resentment, and frustration 
can produce pain similar to the pain of most so-called "organic' intra-abdom- 
inal diseases Usually, abdominal pain of emotional origin can be recognized 
as the symptom of dysfunction in the stomach, small bowel, or colon. It is 
important to localize the pain anatomically because the selection of diagnostic 
procedures is simplified and the patient frequently derives comfort from know- 
ledge that his pain arises in the colon, whereas the bald assertion that the pain 
arises in his head'' leads to confusion, disbelief, and antagonism. 

In a small number of instances, abdominal pain is not due to smooth 
muscular dysfunction but to hysteria. This type of abdominal pain often is 
constant and unchanging for long periods of time and is not accompanied by 
the facial expressions and activities that one associates with a human being 
suffering from the degree of pain the patient claims to have. 

Nonanalgesic sedatives will do little or nothing to the abdominal pain 
that is caused by opiate withdrawal in a patient addicted to narcotics. It is 
all but impossible to separate the anxiety from the pain as each aggravates the 

Apart from opiate addiction, malingering rarely is a cause of abdominal 
pain in general practice It occurs, however, in the child wishing to escape 
punishment or education, the soldier seeking to evade an unpleasant or danger- 
ous assignment, in medicolegal or insurance compensation problems, and 
sometimes as a result of peculiar psychiatric aberrations, particularly in 
persons who have some familiarity with medicine (Mellinkoff, S. M. Systemic 
Causes of Abdominal Pain - Part II: Am. J. Digest. Dis., 4: 642-653, August 
)959) (Part I of this article appeared in the Medical News Letter, 4 September 

9jC Jf $ . $ * ft 

Change of Address 

Please forward requests for change of address for the News Letter to: 
Commanding Officer, U. S, Naval Medical School, National Naval Medical 
Center, Bethesda 14, Md. , giving full name, rank, corps, and old and new 

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Medical News Letter, Vol. 34, No. 6 

Meckel's Diverticulum at a Children's Hospital 

Occurring in one out of 50 persons, Meckel's diverticulum usually 
remains hidden, but may emerge wearing various disguises. This small 
appendage may cause the borborygmus clamor of an acute intestinal obstruc- 
tion on one occasion; at another time, it may assume the pallid countenance 
of an unexplained anemia. Even when simulating the McBurney point pain 
of acute appendicitis, the masque rader succeeds in deceiving nearly every 

A review of the experience at the Buffalo Children's Hospital for the 
past ]5 years revealed that 61 children underwent removal of a Meckel's 
diverticulum for various causes: 17 for intestinal obstruction; )5 each for 
anemia, and recurrent abdominal pain; 7 for perforation with peritonitis; 
6 as an incidental procedure to other operations and one associated with a 
draining umbilical sinus 

Disease of Meckel's diverticulum, because symptoms vary with the 
anatomic and physiologic disturbances resulting from specific affection, may 
be obscure, particularly in children with gastrointestinal tract bleeding and 
abdominal pain. Therefore, with signs of intestinal obstruction, peritoneal 
irritation, or severe anemia, this anomaly should be considered. 

Of the 15 children presenting anemia because of gastrointestinal tract 
bleeding, 11 had massive hemorrhage. Emergency laparotomy was not per- 
formed, with intervention being delayed until stabilization of vital signs by 
blood replacement and subsequent investigation for source of bleeding had 
been accomplished. 

In those patients who presented with intestinal obstruction as the pri- 
mary complaint, the mechanism was intussusception in 10 and volvulus in 7. 
These children were acutely ill and demanded urgent operative intervention. 
In the latter group, the symptomatology did not arouse suspicion of Meckel's 
diverticulum as being the causative factor of the obstruction. 

Of the 22 patients presenting abdominal pain, there were two types: 
those with acute episodes and evidence of peritonitis and those with recurrent 
attacks without symptoms of intestinal obstruction. In the latter group, lapa- 
rotomy was performed as a diagnostic procedure after all other measures had 
not revealed the cause of the pain. 

The authors consider the choice of operative procedure requires indi- 
vidual selection at the time of operation. Primary anastomosis in the pres- 
ence of intestinal obstruction presents excellent prognosis. However, 
Mikulicz's resection should be kept in mind T as the operation of choice for the 
severely ill patient or the child whose intestine is so edematous and friable 
that primary anastomosis is dangerous 

Of the group reported, one death occurred — that of a moribund child in 
whom peritonitis was masked by steroid therapy for Henoch's purpura. 
{Jewett, T.C. , et al. , Meckel's Diverticulum: The Abdominal Ma3querader: 
Surgery, 46: 440-443, August 1959) 

/ Medical News Letter, Vol. 34, No. 6 


Myelofibrosis is an unusual disease characterized by fibrotic or scler- 
otic bone marrow and extramedullary hematopoiesis. First described in 
1871, attention was redirected to it during the third decade of this century 
and it has been better recognized since that time. Myelofibrosis has been 
described uuder a number of terms — agnogenic myeloid metaplasia, aleu- 
kemic myelosis, megakaryocytic myelosis, leukoerythroblastic anemia, 
myelosclerosis, and osteosclerosis. Considerable interest has arisen during 
recent years in regard to its relationship to polycythemia vera and chronic 
myelocytic leukemia. 

The etiology of myelofibrosis in the majority of instances is unknown. 
Exposure to benzene or other bone marrow toxins has been recognized by 
many as an important factor in the development of the condition which results 
in necrosis and finally fibrosis of the bone marrow with compensatory extra- 
medullary hematopoiesis. Also, it is known that 10 to Z0% of cases of poly- 
cythemia vera and some cases of chronic myelocytic leukemia terminate as 
myelofibrosis, although the reverse process more frequently occurs in leu- 
kemia In recent years, the concept has been popular that polycythemia vera, 
chronic myelocytic leukemia, and myelofibrosis are merely different phases 
of 'myeloproliferative disease. " 

The essential pathologic finding is fibrosis of the bone marrow with 
complete replacement by fibrous tissue in some instances. There may be 
patchy areas of very active hypercellular marrow and, characteristically, 
there is megakaryocytic hyperplasia. There may be overgrowth of bone along 
the trabeculae producing sclerosis of bone. Marked extramedullary hemato- 
poiesis occurs. It is most striking in the spleen, less conspicuous in the 
liver and lymph nodes, and minimal ia the kidneys, lungs, and other organs. 

Usually occurring in the older age group, it is equally frequent in both 
sexes. The onset is insidious with presenting symptoms of weakness, fatigue 
dyspnea, and weight loss. Abdominal pain due to the enlarged spleen may be 
a feature as may be a bleeding tendency. 

The blood picture is variable with marked changes of the circulating 
red cells and increase of leukocytes (occasionally low) with a leukemoid left 
shift of the differential white blood cell count. Platelets are usually normal 
or low', but occasionally may be strikingly elevated. The picture may be that 
of chronic myelocytic leukemia. Bone marrow aspiration is unsatisfactory, 
biopsy being required to accurately establish the diagnosis. Progressive 
anemia, frequently of a hemolytic nature, is the common picture with the 
course characterized by bleeding phenomena, infection, and splenic infarc- 
tion terminating as chronic myelocytic leukemia. Duration after diagnosis 
varies from a few months to many years, the average being around 3 to 4 years. 

Myelofibrosis may produce the following roentgen findings: (1) Spleno- 
megaly. This is an almost constant feature without any specific diagnostic 

Medical News Letter, Vol. 34, No. 6 

characteristics (2) Hepatomegaly. A less common feature which is more 
difficult to evaluate roentgenologically (3) Osteosclerosis. This is diffuse 
rather than localized, without expansion of the involved bones or change in 
external contour. The alteration is due to thickening of the individual bone 
trabeculae of the spongiosa and in some cases formation of new trabeculae. 
Apparently, there is no periosteal proliferation of bone, although there may 
be endosteal thickening which involves the diaphyses of long bones. The 
bones exhibiting more apparent changes are the ribs, pelvis, vertebrae, 
clavicles, and scapulae. In many cases only a diffuse increased density of 
the bones with some increased prominence of the trabeculae is seen. In more 
advanced cases of osteosclerosis there are frequently found discrete sclerotic 
foci in addition to the general osteosclerosis. 

Although there are a great many conditions which produce osteosclerosis, 
it is most unusual to encounter a disease which closely simulates the sclerosis 
of myelofibrosis. The bone lesions may be closely mimicked by certain cases 
of metastatic carcinoma and the rare osteosclerotic form of myelomatosis. 
Several other entities at times show osteosclerosis and splenomegaly which 
may be considered in differential diagnosis: Hodgkin's disease, leukemia, 
hemolytic anemia as Cooley's and sickle cell anemia, and Alber s-Schonberg's 

Treatment of myelofibrosis for the most part consists of symptomatic 
and supportive measures. Blood transfusions should be given sparingly with 
the guide being symptoms rather than hemoglobin level. If a significant de- 
gree of hemolysis is present, treatment with adrenocortical steroids may 
prove beneficial. Splenectomy is considered hazardous, although in carefully 
selected patients in whom there had been a significant degree of splenic seques- 
tration and destruction of red blood cells, splenectomy was shown to be bene- 
ficial. Suppression of granulopoiesis by the use of myleran occasionally may 
be of benefit, and irradiation of the spleen has been employed frequently with 
varying results. 

The authors review 25 cases of myelofibrosis seen from 1948 to 1958 
and emphasize the frequency and types of bone changes that may be encountered 
roentgenographically, which changes they consider to be characteristic of the 
disease. (Leigh, T. F. , et al. , Myelofibrosis - The General and Radiologic 
Findings in 25 Proved Cases: Am. J. Roentgenol. , 82: 183-193, August 1 959) 

V T '(* T- *£ ty 

Use of funds for printing this publication has been approved by the 
Director of the Bureau of the Budget, 19 June 1958. 

Medical News Letter, Vol. 34, No. 6 

Results of Treatment of Malignant Melanoma 

Reporting from the Memorial Center for Cancer, the author statistic- 
ally compares the experience with 1,190 cases of malignant melanoma 
treated and followed from January 191V through December 1950 and another 
group of 189 patients confined to the period, January 1948 through December 
1950. From these groups, comparable 5-year period end result studies are 
made. Reviewing the data, the author considers that it is possible to deter- 
mine whether improvement in methods of therapy has occurred and to accredit 
such betterment to certain principles and technique of therapy. 

Although the prevention of malignant melanoma has no bearing on the end 
results of treatment of melanomas already established, certain relevant facts 
about moles established during the past decade are presented. Among these 
facts are the frequency of mole and the rarity of melanoma occurrence which 
confirms the existing policy of not excising all moles. Another fact is the 
development of melanomas during pregnancy which justifies the surgical ex- 
cision of selected darkening moles during the early period of gestation. With 
increasing experience, "the theory that physical trauma can convert a benign 
mole to a malignant lesion is probably becoming untenable. 

An excisional biopsy for melanoma is done only when the primary 
lesion is very large, ulcerating, and fungating; even then it is done with 
utmost gentleness. Small skin lesions suspected of being melanoma are ex- 
cised in toto rather than incised. If a malignant melanoma is found, a three- 
dimensional dissection should be widely and ruthlessly performed. If the 
melanoma is situated in relatively close proximity to the regional lymph 
nodes into which one might reasonably expect lymph-borne metastases to be 
deposited, the lesion may lend itself to a radical dissection — monobloc ex- 
cision or excision and dissection in continuity. The author suggests that a 
situation may exist wherein the primary malignant melanoma is situated in 
the skin at a remote site from the regional lymph nodes involved by metas- 
tasis. Under these circumstances, the recommended procedure is amputa- 
tion or exarticulation of the extremity and dissection of the regional lymph 

Melanomas on the exposed skin of the face are detected earlier than 
elsewhere with the exception of the hand. Therefore, early and definitive 
treatment with improved prognosis — better than for other locations — is now 
experienced. In the 1948-1951 series, the 5-year definitive cure rate was 
39. 5% compared to 18% from 1917 to 1945. 

Because of the vascularity of the region and frequency of blood -borne 
metastases, malignant melanomas of the scalp have been extremely danger- 
ous. The scalping excision should be wide and skin grafting should always 
be necessary. 

Oriy 2. 5% of melanomas occur in the oronasal mucosa, usually on the 
superior or inferior alveoli or on the palate — a region seldom routinely 

Medical News Letter, Vol. 34, No. 6 

examined. Treatment has been by radical surgical excision with only three 
absolute cures reported. 

The comparative incidence of moles to malignant melanomas occurring 
in the skin of the trunk is a ratio of approximately 5 to 3. Regional metas- 
tases to nodes may be widespread. The type of local excision is three- 
dimensional with wide sacrifice of skin and fascia. The outlook for these 
patients has improved over the years with a current 31. 2%, 5-year cure rate 
in the author's series. 

Of 14, 609 nevi counted in adult white patients, only 14 pigmented moles 
were discovered on the vulva and penis — 0, 1% of all moles as compared with 
2. 8% of 1, 222 melanomas. Prophylactic excision of all genital nevi should 
be done, with a more radical procedure for an established melanoma with 
or without metastases. Four of 25 patients with melanoma of the female and 
male genitals were cured {16%). 

Malignant melanomas of the anorectal canal require radical abdomino- 
perineal rectal resection even more urgently than is indicated for the average 
adenocarcinoma of the rectum. This includes a pelvic lymph node dissection 
and bilateral dissection of the inguinal and femoral lymph nodes in continuity 
with the anus. 

Pigmented nevi are not so frequently encountered in the nail bed, but 
should be surgically excised in their entirety. The frequency is approximately 
3 to 3. 5% of all melanomas, occurring more often on the toes than on the 
fingers. The subungual melanomas in one series comprised 44, 8% of all mel- 
anomas of the hand and 13. 1% of all melanomas of the feet. Amputation 
should be above the level of the metacarpophalangeal joint for better functional, 
cosmetic, and curative results. Of 29 cases treated between 1935 and 1950, 
the absolute cure rate was 20. 7%. 

In the 16-year period, 1935 to 1950, 16. 5% of all malignant melanomas 
were on the hands (29) and feet (122). In 32 instances, local surgical measures 
were employed with a 5-year definitive cure rate of 34. 4%; the cure rate for 
all melanomas of the feet was 25. 3%. The latter figure reflects the high mor- 
tality resulting when regional metastasis has .occurred, and more radical pro- 
cedures are mandated. For patients with malignant melanomas of the feet 
having simultaneous nodal metastases in the groin, the 5-year definitive cure 
rate was only 12%. A direct proportion between the diameter of the lesion 
and survival was conspicuous, with those having a lesion 4 to 5 cm. in diameter 
resulting in a cure rate of 10%. The total 5-year definitive cure rate for 
melanomas of the hand was 40%, with a 16. 6% cure rate when metastases 
were present in the axilla. 

In comparing the collective end results of earlier years with the present 
series on the basis of primary location, the following data is presented. This 
improvement can be attributed to: (1) abandonment of radiation therapy as a 
primary therapeutic procedure; (2) education of the lay public and medical pro- 
fession about hazards of certain pigmented skin lesions, resulting in earlier 

10 Medical News Letter, Vol. 34, No. 6 

diagnoses; (3) institution of surgical treatment at a time when the primary 
melanoma often remains localized; and (4) more adequate surgical pro- 
cedures for melanomas — both local and metastatic to regional nodes — based 
on the principles previously stated. 

Location Prior to 1946 

Head and neck 






Lower extremity 



Total experience 












(Pack G. T. , End Results in the Treatment of Malignant Melanoma: Surgery, 
46_: 447-459, August 1959) 

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Pa.get 's Disease 

Paget' s disease is a chronic affection of bones resulting in distortion 
of architecture and alteration of density. It may be isolated or widespread, 
symptomatic or asymptomatic. Almost invariably, it involves the skull and 
those portions of the skeleton which are subject to the greatest stress — ver- 
tebrae, pelvis, and extremities. Characteristic deformities produced by 
change in the bone were best described by James Paget in the latter part of 
the 19th century. 

The frequency of the disease varies from an estimated 3%, as observed 
by Schmorl at necropsy, to about 0. 1% in a study of a general hospital popula- 
tion. This takes on added significance when it is considered that diabetes 
mellitus is observed clinically in slightly less than 2% of the population as a 

Paget' s disease is most commonly observed between the 40th and 60th 
years; it occurs twice as frequently in men as in women, and exhibits no 
relation to race, but seems to have a familial tendency. 

The cause of osteitis deformans is unknown. Studies involving meta- 
bolism abnormalities are hampered by the fact that the abnormality has never 
been produced in laboratory animals. 

Pain is a common symptom of Paget' s disease with back pain frequently 
being caused by collapse of vertebral bodies Nocturnal cramps of the legs, 
when comprising a part of the symptom complex, are best explained on the 
basis of coincident atherosclerosis of the peripheral arteries. Pain in the 
long bones is believed to be due to tortions of the periosteum as a result of 
hyperemia, overgrowth of abnormal bone, and abnormal relationship of perio- 
steum to bone. 

Medical News Letter, Vol. 34, No. 6 ., 

The fundamental lesion of Paget's disease is one of bone destruction. 
The resultant weakness makes the involved bone more susceptible to trauma 
and stress this in turn stimulates an overproduction of bone through the 
osteoblasts. The work of the osteoblasts is never carried to completion and 
the alternating destruction and repair of bone bring about a change characteris- 
tic of the disease. 

The microscopic picture is one of absorption of bone associated with 
over-production of poorly calcified bone so that the disease may be divided 
into (1) the osteoclastic absorption of bone; (2) the osteoblastic formation 
of new bone without calcification; and (3) the osteoblastic formation of new 
bone with calcification. Any combination of these phases may predominate. 

There are usually no changes in the serum calcium and phosphorus levels 
because the osteoporosis of Paget's disease is caused by a disturbance in tissue 
metabolism, and calcium metabolism is involved only secondarily. Hypercal- 
ciuria occurs, particularly when the patient is confined to bed; such a circum- 
stance increases the likelihood of formation of renal calculi. Although the 
serum alkaline phosphatase is usually elevated, the serum calcium and acid 
phosphatase are within normal limits. The serum alkaline phosphatase level 
is almost directly porportional to the degree of bony involvement and can be 
fairly well correlated with the bony changes as demonstrated by roentgenologic 

One of the most interesting aspects of Paget's disease is the involvement 
of the cardiovascular system. Plethysmographic studies indicate that there is 
an increase in blood flow through the bone sufficient to produce changes in the 
general circulation which are similar to those of an arteriovenous shunt. High 
pulse pressure is characteristic, and enlargement of the heart and systolic 
murmurs are frequently observed. It has been shown that there are no signifi- 
cant changes in cardiac output when the disease is monostatic, but in general- 
ized expression of the disease the circulation is greatly increased. In the 
latter cases, one may expect evidence of cardiac failure Occasionally, the 
cardiac output may be increased up to 20 times that of normal. One investiga- 
tor concluded that cardiac output was increased only when not less than 35% of 
the skeleton was involved. 

Arteriosclerotic or hypertensive cardiovascular disease is not an in- 
frequent concomitant occurrence. Of interest is the report of valvular cal- 
cification which is assumed to be a result of disturbed calcium metabolism. 

From reports of various observers, it would appear that Paget's disease 
may be considered a pre sarcomatous lesion. When a diagnosis of bone sar- 
coma is made, thorough examination of the skeleton should be conducted for 
evidence of Paget's disease. 

Among other complications are extensive choroidal changes, retinal 
hemorrhages, optic atrophy (possibly due to compression of the optic nerve 
by bone changes in the skull), diplopia, keratitis, and corneal opacities. The 
classical x-ray picture of Paget's disease is one of change in the architecture 

.„ Medical News Letter, Vol. 34, No. 6 

of the cortex and medulla as well as varying degrees of hyperplasia or thick- 
ening of bone incident to the activity of osteoblasts. Changes in the skull 
and pelvis are described as presenting a cotton-wool appearance. There 
may be enlargement of the involved part of the skeleton with flattening, 
along with specific changes of localized areas. Among typical findings, 
perhaps the major ones are: (1) widespread honeycomb or spongy appear- 
ance; (2) striated appearance in pelvis and sacrum; (3) uniform and in- 
creased density in the vertebrae; and (4) true cystic areas of pelvis and long 

Although there are some reports of benefits from the use of steroids, 
there is no known treatment for Paget' s disease. Some investigators believe 
that a decrease in bone absorption is brought about by an increase of calcium 
and phosphorus intake as well as administration of large doses of vitamin D. 
Continued activity and full ambulation of patients is urged since it is well 
recognized that immobilization results in decrease in bone repair, and osteo- 
porosis of disuse accentuates that resulting from the physiologic processes of 
the diseased bone. (Engelhardt, H. T. , Earl, D.M. , Baird, V. C. , Paget's 
Disease - Current Concepts as Exemplified by Case Histories: Geriatrics, 
L4: 500-510, August 1959) 

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Vitamin Bj2 and Folic Acid in Medical Practice 

Vitamin B ^ and folic acid are now established parts of the complex 
of essential nutrients often referred to as the "B vitamins. " Since they are 
nontoxic — at least to normal individuals — they are dispensed freely in multi- 
vitamin pills and are prescribed promiscuously on a nonspecific or 'tonic' 
basis for patients with a variety of ailments. 

Folic acid was the first to be discovered as the culmination of a series 
of independent observations. It is a nutrient essential for bacteria, avian 
and mammalian species, and man. It is particularly concerned with meta- 
bolic reactions involving synthesis of essential amino acids and constituents 
of nucleoproteins. In hematopoiesis, its lack results in abnormal blood 
formation characterized by megaloblastic erythropoiesis, abnormal leuko- 
poiesis, and formation of a deformed, abnormally large, red blood cell with 
a shortened life span. 

The effect of folic acid in pernicious anemia is limited to the blood, 
in many cases aggravating the neurologic lesions of that disease. It cures 
other megaloblastic anemias, such as sprue, nutritional anemias, and 
anemias of infancy and pregnancy. 

Following the discovery by Minot and Murphy that ingestion of liver 
cured pernicious anemia, the search for the factor responsible for this effect 
was relentless. By 1947, some crystals containing cobalt were isolated and 

Medical News Letter, Vol. 34, No. 6 13 

designated vitamin B _. Clinical studies followed immediately with well 
known success. 

The complete details of the biologic effects of these substances have 
not been clarified. However, it is believed that both are involved in the syn- 
thesis of DNA {deoxyribonucleic acid) of the cell nucleus. The exact steps 
in the synthesis where each one works are not yet established. Both are essen- 
tial and when one is given, the reaction involving the other is speeded up. When 
the concentration of either reaches a low level, the reaction of nucleoprotein 
synthesis cannot go on and megaloblastic red blood cell formation results. 
Under these conditions, the use of the vitamin that is not lacking may have a 
slight effect, good effect, or no effect A good effect is followed by a period 
of refractoriness. Therefore, those patients with pernicious anemia who 
respond to folic acid sooner or later will require larger and larger doses and 
.eventually will become totally refractory to it. In addition to the "role in hemat- 
opoiesis, vitamin Bit still plays an obscure but essential role in preservation 
of neuronal integrity. 

Daily requirements for vitamin Bt? are so small that it is almost imposs- 
ible to find a diet so deficient in it that signs or symptoms of deficiency will 
develop. Deficiency is almost always the result of defective absorption of the 
vitamin from the gastrointestinal tract which is a specific function of the small 
intestine, actuated by an enzyme of the gastric mucosa — the "intrinsic factor" 
of Castle. 

After absorption, vitamin B^ i- 3 bound to a beta globulin in the blood 
stream and transported to the tissues and the liver for storage. Since the 
binding protein in the blood is limited in amount, doses of the vitamin in ex- 
cess of 50 meg. are carried in the uncombined or free form. The bound form 
cannot pass the kidney barrier while the free form is rapidly excreted during 
the first 24 hours following injection. 

It is apparent that the two vitamins discussed— although having much in 
common — cannot be used interchangeably. Vitamin B^ is "the missing factor 
in pernicious anemia and folic acid is specific for the other megaloblastic 

Sprue is a malabsorption syndrome responding well to folic acid, 
orally or parenterally, although there is a group of patients with sprue that 
show an abnormal absorption of vitamin B^ and, therefore, should receive 
both substances when receiving therapy. 

The dosage of folic acid is 5 mg. daily until remission is obtained. 
The patient with sprue may require maintenance therapy. Vitamin "Byi ^ or 
the patient with pernicious anemia is given intramuscularly, 50 meg. weekly. 
After response, a maintenance schedule of an injection every 2 weeks is pre- 
ferred to a monthly injection. Patients with degenerative spinal cord disease 
should be treated more vigorously— 50 meg. three times a week until remiss- 
ion, then maintenance injections every week. 

In recent years, the market has been flooded with oral preparations 
containing vitamin B\2 and concentrates of intrinsic factor. The uncertainty 

14 Medical News Letter, Vol. 34, No. 6 

of action, of these preparations and their expense should discourage their 
use. The use of either folic acid or vitamin B^2 i- n anemia or neurological 
conditions of types other than those discussed has not resulted in definite 
evidence of effectiveness. Any benefits reported are considered to be 

Specific admonitions by the author are: 

(1) Don't give folic acid to patients with pernicious anemia. Several 
cases of severe cord disease have developed in patients who did not know they 
had pernicious anemia and were taking multivitamin pills which contained 
folic acid. Don't prescribe them. 

(2) Don't waste large oral doses of vitamin Bj2 on patients who do not 
have pernicious anemia or small ones on patients who do. 

(3) Don't give injections of vitamin Bit greater than 50 meg. unless 
there is some particular reason for it, psychologic or experimental. 
(Reisner, E. H. , Jr. , Vitamin B^ and Folic Acid in Medical Practice: 
GP, XX: 94-97, August 1959) 

Tired Mother Syndrome 

Most young mothers are tired. Some are tired occasionally, others 
almost all the time. Seldom is this fatigue due to organic disease. There are 
just too many things for them to do in too short a time ! A tired mother is not 
necessarily maladjusted — she is spent; not burdened with guilt — merely overly 
conscientious; and, most important of all, she is not sick— just tired. 

Physicians, in their desire to be of service, often forget this, as 
witness the long list of medications prescribed to be swallowed or injected 
for the relief of fatigue. Study indicates strongly that young mothers are supp- 
osed to be tired and supports the concept of an entity called the tirea-mother 

Because fatigue cannot be measured objectively, the severity of the 
problem largely depends on how graphic a description the patient herself 
offers. The syndrome usually afflicts a worrisome, tense, overly conscien- 
tious mother who cannot quite keep up with all the tasks she has set for herself. 
She begins to feel tired, run-down, and irritable; any of a large number of 
somatic symptoms may develop which worry and confuse her. Her reading of 
medical articles in women's magazines having acquainted her with a number of 
major diseases, she soon is prepared to accept the fact that she has one or 
even several of them. 

Some women are beset with great problems — others with only a never- 
ending series of minor ones. Despite labor saving devices at home, life has 
become more complicated— not less. The modern mother is required to be 
handyman, chauffeur, child psychologist, and clubwoman. Her calendar is 
crowded with many activities. 

Medical News Letter, Vol. 34, No. 6 ,- 

Of the subtypes of tired mothers, the working mother is a common one. 
The older mother type has a difficult time — for her, all activities of the usually 
busy mother are just a bit more difficult. The displaced-person tired mother 
type is a woman-in-a-hurry. In addition, there are those individuals with a 
low or high energy reserve, both of which types may overspend their supply, 
resulting in a negative balance and weariness. 

The amount of work accomplished is not necessarily an index of the 
amount of nervous energy used, since worry, indecision, and unhappiness drain 
off more than does purposeful activity. Thus, the tired mother may be constantly 
fatigued even though she accomplishes little. 

Over several months, 211 women with the complaint of tiredness were 
given complete general physical examinations. Of these women, 60 had one 
child or more under 16 years of age. Twenty-eight subjects Used as ''normal'' 
tired mothers were women of average emotional stability without any major 
problems contributing to a situational anxiety reaction. They were just trying 
to do too much. 

Analysis shows that the number of children being reared by tired 
mothers has no bearing on the problem. Apparently, a tired mother with one 
child worries four times as much per child as the mother with four children. 

Prior to being observed by the author, the usual treatment, given to the 
patients in this series had been vitamin injections with vitamin B ,-> leading the 
list — more popular than vitamin Bj or tranquilizers. Six patients were given 
estrogens without being menopausal. 

The results of treatment depend on how much underlying neurosis is 
present. In the relatively ''pure 1 ' tired-mother syndrome almost anything seems 
to be effective since the condition is self-limited. Unfortunately, in the offices 
of too many harried physicians, three main methods of treatment are utilized: 

1. Substitution method. An organic -sounding term is used to explain 
the fatigue, although no organic disease actually is present. This substitute 
organic condition — ''anemia, ' ''low blood pressure, " "hypometabolism" 
,: female trouble"— may then be treated vigorously. 

2. Subtraction method. In this system, the fatigue is blamed on some 
bad habit. The offending agent — excessive eating, tobacco, coffee, alcohol — 
is therefore subtracted or taken away. The discerning physician can find 
something to take away from almost everyone. 

3. Subalimentation theory. The proponents of this theory hold that 
when no organic disease can be demonstrated, chronic fatigue must be due 
to poor eating habits and subsequent lack of vitamins. The efficacy of 
various vitamin preparations in prevention and treatment of ordinary 
nervous fatigue can be judged by the fact that while consumption of them is 
at an all-time high, so, too, is the number of tired people. 

It is important. to realize that most tired mothers are not being treated 
by the medical profession. Spurred on by lurid commercial advertising and 
quiz show sponsors, tired people throughout the land are turning to patent 
medicines for infusions of pep and energy. The fountain of youth has been 

,, Medical News Letter, Vol. 34, No, 6 

discovered on Madison Avenue; its elixir has been bottled, labeled, and dis- 
tributed so that all can partake of it. The concept of "tired blood" may not 
be based on sound medical principles, but it represents a triumphant example 
of the adman's art. 

Following the preferred method of treatment, use of placebos and 
other psychologic aids under the supervision of the medical profession is not 
to be condemned. Emotional support always has been — and will remain — one 
of the most valuable phases of therapy. However, in management of the tired- 
mother syndrome, no medication can take the place of the physician's forthright 
assurance based on confidence acquired from a careful and thorough physical 
examination. The non-neurotic mother appreciates knowing that all mothers 
are tired at one time or another and that her complaint is not unusual. 

Medication can and should be used for symptomatic relief. When fatigue 
is a manifestation of underlying neurosis, treatment is much more difficult. 
Particularly tragic are those instances associated with serious situational 
problems that cannot be resolved. Beyond measures contributed by the phys- 
ician, there are many other things that may induce remission — often simple 
things, but important just the same. 

Fortunately, the majority of tired mothers are not afflicted with neuroses. 
The physician must teach her that individuals^are born with variable amounts of 
drive and nervous energy and that each must learn to live within her supply. 
(Lovshin, L. L, , The Tired Mother Syndrome: Postgrad. Med. , 26: 48-54, 
August 1959) 


BUMED INSTRUCTION 6230. 10 25 August 1959 

From: Chief, Bureau of Medicine and Surgery 

To; Ships and Stations Having Medical Corps Personnel 

Subj: Vaccinia immune globulin; availability of 

The purpose of this instruction is to advise addressees of the availability of 
vaccinia immune globulin for treatment of military personnel and their de- 
pendents with early cases of generalized vaccinia, eczema vaccinatum, 
progressive vaccinia, vaccinia necroaum, and other serious complications 
of smallpox vaccination. 


Medical News Letter, Vol. 34, No. 6 ±7 

Letters of Congratulation 

On the occasion of the 117th anniversary of the establishment of the 
.Bureau of Medicine and Surgery which was observed on 3 1 August 1959, Rear 
Admiral Bartholomew W. Hogan, Surgeon General of the Navy received the 
following congratulatory letters: 

"I have the honor to extend heartiest congratulations and best 
wishes from the United States Marine Corps to you and to the other 
members of the Navy Medical Corps upon the occasion of the 117th 
anniversary of your organization. 

An anniversary is an occasion for reflection, and you can 
reflect with the deepest pride upon the distinguished record of the 
Navy Medical Corps over the years. It is a record of courage, de- 
votion to duty, high professional competence, and compassionate 
service to humanity. We Marines have the highest esteem for all 
of you, and we cherish the strong bonds of friendship which have 
developed through the years between the Navy Medical Corps and 
the Marine Corps. 

With warmest personal regards and every good wish for the 
continued success of your Corps throughout the years ahead, I 


s // R. McC. Pate 
U. S. Marine Corps" 

"On 31 August 1959, the Navy Bureau, of Medicine and 
Surgery will celebrate its 117th anniversary. The entire Army 
Medical Service joints me in offering congratulations and best 
wishes for another peaceful, productive year ahead. 


s // Lejonard D. Heaton 
Major General, MC 
The Surgeon General" 

Medical News Letter, Vol, 34, No. 6 


From the Notebook 

Space Suit . Navy's newest aluminized full pressure omni- environmental suit, 
in competition with other pressure suits, was selected for use by the astro- 
nauts who are to fly in Project Mercury. This suit was developed by the Air 
Crew Equipment Laboratory at Philadelphia under the direction of Naval Av- 
iation Medicine personnel. The space capsule destined to carry the first 
astronaut will be tested by the Navy at the same laboratory. 

Armed Forces Medical Journal . The October issue of the United States Armed 
Forces Medical Journal will present an entirely new appearance. COL Robert 
J. Benford USAF MC, editor, announces that letterpress printing will be em- 
ployed replacing the varitype photo-offset method which has been used for 
many years. This will give the Journal a more attractive aspect and easier 
to read type. In other regards, much of the appearance of the Journal has 
been altered, including the cover which will be distinctive and modern. Intro- 
duction of new features and other interesting changes are being planned for 
issues in the near future. 

ADA Meeting . LCDR Lucille R. Clark, MSC USN and LT(jg) Martha J. Svete 
MSC USNR, both stationed at U.S. Naval Hospital, San Diego, represented the 
Bureau of Medicine and Surgery at the 42nd Annual Meeting of the American 
Dietetic Association at Los Angeles, 25-27 August 1959. During the sessions 
these officers monitored a booth which contained a series of enlarged color 
photographs depicting the professional duties of the Navy dietitian. 

Left Ventricular Hypertroph y. Evaluating the reliability of criteria for electro- 
cardiographic diagnosis of left ventricular hypertrophy, correlation of the 
features of tracings with anatomical findings was made in 200 successive 
patients who exhibited left ventricular hypertrophy at autopsy. The most sig- 
nificant abnormalities were the characteristic ST-segment and T-wave changes 
which were seen in 55%(80% if patients with obvious myocardial infarction or 
bundle-branch block were excluded). Amplitude of the QRS complex was 
quite unreliable, with only 22% showing this variation. ( A. H. Griep, 
Circulation, July 195 9) 

Acute Cholecystitis , The author endorses the conservative treatment of acute 
cholecystitis, including nasogastric suction, intravenous fluids, sedation and 
occasionally antibiotics. When surgery is required, simple gallbladder 
drainage is often adequate. Acute cholecystitis presents special problems in 
older patients. Possibility of gallbladder rupture is not a valid excuse for 
immediate surgery. (E. T. Thieme, GP, August 1959) 

Medical News Letter, Vol. 34, No. 6 jg 

Gastric Pepsin . Cognizant of the possibility of a relationship between ABO 
blood groups and secretion of gastric pepsin with increased frequency of 
peptic ulcer disease in patients with polycythemia and leukemia, the authors 
reviewed a series of patients. The excess of group O blood type and concen- 
tration of plasma pepsinogen was not significant in the patients with either 
disease. The increased occurrence of peptic ulcer claimed for these two 
diseases, if indeed real, they considered to be due to factors other than el- 
evated acid-pepsin activity. (M. L. Sievers, P. Calabresi, Am. J. Dig. Dis. , 
July 1959) 

Thymectomy in Myasthenia Gravis . From review of current literature and 
their own experience, the authors conclude that most young women with myas- 
thenia gravis of 2 to 3 years duration and no evidence of thymic tumor should 
undergo exploration as well as all patients with suspected thymic tumors with 
or without myasthenia gravis. Thymectomy in male patients and radiation 
therapy is considered to be of doubtful value. (H. H, Olson, et al. , Am. J. Surg. , 
August 1959) 

Coronary Vasodilator . Vasoflex (N-cinnamyl-methylamino-2-phenylpropane 
hydrochloride), a drug related to the catechol amines, was studied by the 
authors. Their findings confirm that a vasodilating effect results from intra- 
venous use, ■without any marked alteration of heart rate and arterial blood 
pressure, but accompanied by an increased cardiac output, left ventricular 
work, and left ventricular oxygen utilization. Therefore no net benefit is 
realized. (E. Traks, et al. , Ann. Int. Med., July 1959) 

Serum Amylase Test . This test alone cannot be used to differentiate between 
obstructive biliary lithiasis without pancreatitis, pancreatitis without biliary 
lithiasis, and concomitant pancreatitis and biliary lithiasis. Elevations of the 
serum amylase above 500 Somogyi units /100 ml. may occur in the complete 
absence of demonstrable pancreatic disease. Accurate assessment of the 
merits of "conservative" or "nonoperative" regimens of treatment of acute 
pancreatitis is impossible — the diagnosis of pancreatitis cannot be made with 
certainty without an autopsy or celiotomy. (H. Bernard, A. M. A. Arch. Surg. , 
August 1959) 

Liver and Tuberculosis . Until recently the liver seldom has been considered 
to be a site of tuberculous involvement except in cases of acute miliary tuber- 
culosis or as a result of terminal hematogenous dissemination. Performing 
liver function tests in 50 patients with extrapulmonary tuberculosis, abnormal- 
ities of hepatic function and plasma proteins were demonstrated in almost all 
patients. A high incidence of granulomas and other histologic changes were 
observed in the liver biopsy specimens of 30 patients. (R. J. Korn, et al. , 
Am. J. Med. , July 1959) 


Medical News Letter, Vol. 34, No. 6 

Wound Infections. Study of acute traumatic and elective surgical wounds 
indicates that bacteria which are present at the time of wound closure are 
the origin of surgical wound infection. Meticulous wound excision followed 
by copious irrigation with normal saline will reduce the incidence of wound 
infection — antibiotics will not. (F. P. Shidler, Am. J. Surg. , August 1959) 

Bacteria in Liver Disease . From their study of patients with various diseases 
of the liver, the authors conclude that the data available suggests that bac- 
teria are not ordinarily found in the human liver or portal vein blood, but 
that they may invade the portal vein under unusual physiologic circumstances, 
such- as abdominal trauma, surgery, irradiation, shock, anoxia, or other 
circumstances leading to local changes in the intestinal wall. (J, M. Stor- 
mont, et al. , Ann. Int. Med, July 1959) 

Risks of Aminophylline . Aminophylline intoxication is difficult to recognize. 
The drug has produced at least 14 deaths and 53 cases of serious toxicity in 
children. The most serious problem is overdosage. Caution is urged in the 
intravenous use of the drug in patients with limited cardiac function and in 
children who show a marked sensitivity to the drug's central nervous system 
stimulant effect. (E. B„ Truitt, GP, August 1959) 

Test of Pituitary Reserve. SU-4885 inhibits 11/3 -hydroxylation of steroids by 
the human adrenal cortex and leads to a decrease in Cortisol secretion, a 
"compensatory" rise in ACTH secretion, and secretion of large quantities of 
11-desoxycorticosteroids such as compound S. In normal subjects this sub- 
stance induces a rise in total blood and urinary 17-hydroxycorticoids and 
provides a sensitive means of testing the reserve capacity of the pituitary 
gland to secrete ACTH. (G. W. Liddle, et al. , J. Clin. Endocrinol. , 
August 1959) 

Antibiotics and Anesthesia. Antibiotic administration during surgery may be 
associated with hazards not normally encountered in unanesthetized subjects. 
The potential dangers are not those usually associated with prolonged repeated 
administration of these drugs such as allergic responses and blood dyscrasias 
but rather acute states of respiratory or circulatory depression. (C. B. 
Pittinger and J. P. Long, A. M. A. Arch. Surg., August 1959) 

Strokes . A pamphlet prepared by the American Heart Association, "Strokes, 
a Guide for the Family, " is available as a guide for those concerned with the 
rehabilitation of the stroke patient in the home. This booklet, available to 
physicians and therapists in quantity for distribution to the families of stroke 
patients, may be obtained from local heart associations or by writing to Amer- 
ican Heart Association, 44 East 23rd Street, New York City. 

A A ft A rft nfc 

Medical News Letter, Vol. 34, No. 6 




Tranquil! zing Drugs in Oral Surgery 

The use of promazine and meprobamate to control postoperative 
sequelae in oral surgery was clinically evaluated in 150 military patients. 
"When the results of ataractic drug therapy were compared to those of placebo, 
no significant effect was noted on the postoperative sequelae of pain, swelling, 
or trismus. Tranquilizing drug therapy failed to influence the postsurgical 
narcotic demand. The incidence of untoward reactions was not significantly 
increased. The number of days lost during postsurgical convalescence was 
increased significantly for patients on promazine and meprobamate therapy. 
On the basis of these findings, the use of promazine or meprobamate cannot 
be recommended for the control of postoperative sequelae in oral surgery. 
(L. Smyd, CM. McCall, E. T. Enright, Tranquilizing Drugs in Oral 
Surgery, Rep. , School of Aviation Medicine, Randolph AFB: Technical Abstract 
Bulletin No. U59-9, (ASTIA) 1 May 1959) 

Navy Exhibits at Centennial Session of A. D. A. 

Two Navy Dental Exhibits will be shown at the Centennial Session of 
the American Dental Association in New York from September 14 to 18, 1959. 

The first exhibit is the U.S. Navy Dental Corps' "Casualty Treatment 
Training Program II. " This exhibit illustrates various phases of the casualty 
treatment program for Naval Dental officers. Some of the training aids 
developed by the U.S. Naval Dental School, National Naval Medical Center, 
Bethesda, Md. , to develop skill and dexterity in treating casualties are fea- 
tures. An outstanding feature is a model of a military casualty fitted with 
special types of moulages simulating different injuries. The viewer is chal- 
lenged to decide how he would handle the injuries. A demonstration of the 
accepted emergency treatment for each of the simulated injuries is made at 
intervals during display of the exhibit. Additional emphasis on accepted 
emergency treatment is created by illuminated still photographs and by use 
of an automatic slide projector. The aim of the exhibit is to create in Naval 
and civilian dentists an interest in participation with Civil Defense authorities 
at the professional level as demonstrated in the exhibit. 

_- Medical News Letter, Vol. 34, No, 6 


The second exhibit is "First .Line Dentistry for the First Line of 
Defense. " This exhibit is designed to depict a wide variety of professional 
subjects. The topics are illustrated by color transparencies, art presenta- 
tions, and training aids. The monitor chooses a subject by illuminating a 
sliding panel, one for each subject, and illustrates and supplements his 
talk with training aids. 

The monitors for the "Casualty Treatment Exhibit" will be CDR J. D. 
Shaw and CAPT H. J. Towie DC USN; for "First Line Dentistry, monitors 
will be CAPT G. W. Ferguson and CAPT J. B. Ferris DC USN. 

if. if. if. if if % 

Anniversary Greetings from Commandant 
of Marine Corps 

General R. McC. Pate, Commandant of the Marine Corps, on 2] 
August 1959, addressed the following letter to Rear Admiral C. W, Schantz, 
Assistant Chief for Dentistry, and Chief, Dental Division, Bureau of Med- 
icine and Surgery: 

"I with to extend to you the heartiest congratulations of the Marine 
Corps on this 47th Annivers-ary of the Navy Dental Corps. 

"The readiness of our combat forces depends not only upon training 
and equipment, but also upon the physical fitness of the individual Marine 
as well. The Marine Corps appreciates the effort expended by the officers 
and men of your Corps toward accomplishing this task. 

"Again, congratulations for the achievements of the past year and best 
wishes for the next. " 

* >|c # # * * 

Philippine Armed Forces Dental Service Anniversary 

The Dental Service of the Philippine Armed Forces recently celebrated 
its Fifth Anniversary in Manila, Philippine Islands, with a two -day program 
of events. The first day was devoted to scientific sessions and the second 
to social affairs. 

Among the essayists of the first session was Captain A. K. Kaires, 
DC USN, Senior Dental Officer, U.S. Naval Station, Sangley Point who 
presented a paper on "Occlusal Equilibration. " 

jje * # * sit * 

Medical News Letter, Vol. 34, No. 6 23 

Navy Dental Corps' Continuous Training Program 

A short course in Oral Surgery will be conducted at the U, S. Naval 
Dental School, National Naval Medical Center, Bethesda, Md. , September 
21 - 25, 1959. 

The course will consist of s,eminars, lectures, and demonstrations. 
It is intended to cover treatment of facial fractures and othe.r oral surgical 
procedures, local and general anesthesia, premedication, principles of 
exodontia, and biopsy techniques. Emphasis will be placed on preoperative 
evaluation and minimal postoperative complications. 

The instructor is CAPT D. E. Cooksey DC USN, Diplomate, American 
Board of Oral Surgery. 

% >J; sje )(: ;fc J&: 

Scientific Session of Federation 
Dentaire Internationale 

Reserve officers will be credited with one retirement point for attend- 
ing the scientific session of the 47th Annual Session of the Federation Den- 
taire Internationale Meeting at the U.S. Military Adademy, West Point, 
N. Y, , on 11 September 1959. Officers planning to attend must arrive at 
the Military Academy Main Gate, prior to 1:00 p. m. , via their own trans- 
portation. They will be met there by a Naval representative who will escort 
them in a body to Thayer Academic Hall for the scientific sessions. 

These sessions will commence at 1:15 p. m. , and after a discussion 
period will adjourn at 3:45 p, m. The program will include: 

1. The Role of the Royal Naval Dental Service 

Surgeon Rear Admiral (D) Charles J. Finnigan 
L. D. S. , Q. H. D. S. , Deputy Director General for 
Dental Services, Royal Navy, Great Britain 

6. Medical Management of Mass Casualties 

Colonel Thomas A. McFall DC USA, Director 
Division of Dentistry, Walter Reed Army Institute 
of Research, Walter Reed Army Medical Center 

3. Aerodontalgia 

Colonel Harold E. Kelley (DC) USAF, Deputy for 
Preventive Dentistry and Research Office of the 
Assistant for Dental Services 

2 4 Medical News Letter, Vol. 34, No. 6 

4. Submarine Medicine and Cold Weather Dentistry 

Captain William R. Stanmeyer DC USN, Head, 
Professional Branch, Dental Division 

3p T "T* "'P "T" *T^ 

BUMED INSTEUCTION 67QJ. 5B 11 August 1959 

From: Chief, Bureau of Medicine and Surgery 
To: Distribution List 

Subj: Medical and Dental Spaces in Vessels of Reserve Fleets 

Ref: (a) Ship Activation Manual (NavPers 1J006), Chapter 22 

End: (1) Procedures for Inactivation of Medical and Dental Spaces 
Aboard Ships Entering the Reserve Fleets 

This instruction announces procedures for activation and inactivation of 
medical and dental spaces in vessels of Reserve Fleets. 

tA» -Jr jjf *■'«• 5V 5& 


Change in Active Duty Policy for Enlistees 

Young men between the ages of 17 and 26 who are not high school 
students now may enlist in the Naval Reserve for participation in a drilling 
unit or for immediate performance of 2 years' active duty. Formerly, men 
between the ages of 18-1/2 and 26 could enlist in the Naval Reserve only for 
immediate active duty. 

The change in policy will enable this older age group to affiliate with 
a drilling unit and complete basic training before being ordered to full-time 
active duty. 

Those enlisting for drill participation will be required to perform 
the first 14-day period of active duty for training within 120 days of enlist- 
ment. Orders to full-time active duty will be delayed until advancement to 
pay grade E-2. Normally, the delay in receiving active duty orders will 
not exceed 12 months; however, additional delay may be granted to Reservists 
who may be able to complete an accelerated training program. 

Medical News Letter, Vol. 34, No. 6 


Reservists failing to continue satisfactory participation in unit drills 
will be subject to orders to immediate active duty. 

The policy for high, school students between the ages of 17 and 18-1/2 
enlisting in the Naval Reserve remains unchanged. 

Additional information may be found in a revision of BuPers Instruction 
1130.5 which will be published soon. (The Naval Reservist, August 1959) 

Reserve Hospital Corps Division Activated 

The Naval Reserve Hospital Corps Division 5-1 was activated and 
established recently at the National Naval Medical Center, Bethesda, Md. 
This paid drilling unit of the active fleet augmentation components of the 
Selected Reserve Forces conducts multiple drills on the second weekend 
of each month. Training commences at 0800 on Saturday and ends on the 
following Sunday at 1630. Thus, four drills are conducted on a weekend 
and no other drills are scheduled during the same calendar month. The 
unit consists of 5 officers and 50 enlisted hospital corpsmen, the latter 
receive instruction and training enabling them to qualify for advancement 
in rating. CDR J. W. Walsh MC USNR is the Commanding Officer; LCDR 
P. Bayer USNR is Executive Officer. 

Interested eligible Naval Reservists may obtain information regard- 
ing affiliation with this Division by writing CDR Walsh at the U. S. Naval 
and Marine Corps Reserve Training Center, Silver Spring, Md. 

$ $ $ $ # s[c 

Tables of Organization for Naval Reserve, Fiscal Year I960 
BuPers Instruction 5400. 1H, 1 July 1959 
General Provisions 

1. General Information . The Chief of Naval Operations has established 
Selected Reserve Forces within the Naval Reserve and has allocated ceilings 
for each drill pay program of the Naval Reserve for fiscal year I960, deter- 
mined on the basis of mobilization requirements. The Tables of Organiza- 
tion for Naval Reserve, Fiscal Year 1960, includes the drill pay programs 
in the Selected Reserve under five basic components: 

a. Antisubmarine Warfare c. ^Active Fleet Augmentation 

b. Mine Warfare* d. Fleet Support Activities 

e. Shore Establishment 
* Under development for implementation 
The authorized number of units included in the Tables of Organization exceed 
the allocated cei-lng sufficiently to insure that actual on-board numbers are 

2/ Medical News Letter, Vol. 34, No. 6 

sufficient to meet mobilization requirements. The Tables of Organization 
numbers will be reduced on an annual basis to more realistically match 
mobilization requirements. The Chief of Naval Personnel administratively 
controls these numbers as necessary to preclude exceeding the drill pay 

2. Drills 

a. Number 

(1) Naval Reservists assigned in pay status to units of the Selected 
Reserve Programs listed below may be paid for attendance at a maximum 
of 24 or 48 drills as appropriate for the table indicated. Drills may be 
scheduled in such numbers as necessary to insure that members have an 
opportunity to attend the maximum number of paid drills authorized. 

Paid Drills Table 

48 1-12, 14, 17-19, 21-23, 

24 13, 15, 16, 20 

(2) Pay is not authorized for units of the Specialist Programs except 
that certain members of these programs in Ready Reserve status may receive 
pay for the faithful performance of duties in connection with the administra- 
tion and training of their units. This matter is discussed in paragraph 7. 

b. Frequency 

(1) Selected Reserve Programs . Within the annual maximums shown 
above, paid drills may not be credited to an individual in excess of the rates 
listed below, except that members of units authorized 24 paid drills annually 
may be paid for attendance at a maximum of three paid drills during a cal- 
endar month in those cases where attendance at a scheduled equivalent drill 
would exceed the maximum of two: 

Max. Auth . Max. Auth . Max. Auth . Max. Auth . Max. Auth . 

Annually Per Quarter Per Month Per Week Per Day 

48 13 6 3 2 

24 6 2 2 2 

(2) Specialists Programs. All Specialist Programs except the NROS 
Program are authorized to schedule 24 drills annually. If the unit commanding 
officer desires to afford members of his unit more training than that offejred 
through the regular curriculum or more training by expanding the regular 
curriculum, or if the unit desires to undertake a special project or study, 
which is in consonance with the specialty of the program concerned, an addition- 
al 12 or 24 drills may be scheduled with the approval of the Commandant. Drills 
may not be credited to an individual in excess of the rates listed below: 

Max. Auth . Max. Auth Max. Auth . Max. Auth . Max. Auth . 

Annually Per Quarter Per Month Per Week Per Day 
48 13 6 3 2 

36 10 4 2 2 

24 8 3 2 2 

Medical News Letter, Vol. 34, No. 6 __ 

(a) The maximums established above for twenty-four drills 
annually are also applicable for those members authorized to receive pay. 
c. Type 

(1) Regular drills are described in detail in the BuPers Manual. 

A regular drill is a period of not less than 2 hours and is the only drill con- 
ducted in any one calendar day. 

(2) When two or more drills are conducted in any one calendar day, 
they shall be considered as multiple drills and each drill shall be of at least 
4 hours duration. Multiple drills are authorized for all Selected Reserve 
Programs of the Naval Reserve. 

(3) Drills may be scheduled in increments in accordance with the 
BuPers Manual. 

3. Active Duty for Training . An individual must be a member of the Ready 
Reserve to be eligible for active duty for training with pay. Further, the 
following conditions apply: 

a. With Pay 

(1) Required . Annual active duty for training with pay, normally for 
a period of fourteen (14) days, is authorized within the limits of funds avail- 
able for personnel assigned to units of programs listed in Tables 1 through 
23, 27, and 28. 

(2) Authorized . Annual active duty for training with pay, normally 
for a period of fourteen (14) days, is authorized within the limits of funds 
available for personnel assigned to units of programs included in Tables 24 
and 25, and for personnel under' appropriate duty orders in accordance with 
Table 26. Within the provisions of other current, applicable directives, a 
period of twenty-eight (28) days annual active duty for training with pay is 
authorized, within budgetary limitations, for members of the Naval Reserve 
assigned to Naval District Active Status Pools in Training Category H. 

b. Without Pay . Active duty for training without pay, normally a period 
of fourteen (14) days, is authorized within the limits of funds available for 
transportation and subsistence allowances, for the following members of the 
Naval Reserve: 

(1) Those who are not eligible for active duty for training with pay. 

(2) Those who have been unable to take active duty for training with 
pay for lack of funds. 

(3) Those who are granted periods of active duty for training in excess 
of fourteen (14) days (exclusive of travel time). 

c. Special Active Duty for Training . Special active duty for training, 
with or without pay, for periods in excess of fourteen (14) days but not more 
than ninety (90) days duration including travel time, may be performed for 
special purposes by Naval Reservists upon approval of the Chief of Naval 
Personnel. Requests for active duty for training in excess of fourteen (14) 
days must be fully justified and favorably recommended by cognizant commands. 


Medical News Letter, Vol. 34, No. 6 

d. Group Active Duty for Training. Group active duty for training shall 
be authorized and conducted in accordance with the instructions contained in 
Article'H-4204 of the BuPers Manual. 

NOTE; Additional excerpts from this important Instruction will be published 
in succeeding issues of the Medical News Letter. 

$ 3$C a£ $S 9ft _$ 


Respiratory Virus Diseases 

Hardly a month goes by without the discovery of a new virus affecting 
the respiratory tract. Apart from the influenza virus which caused a world- 
wide epidemic, there are many such viruses which are more easily distin- 
guished from one another by serological tests than by the clinical syndromes 
which they cause. They are responsible not only for acute feverish catarrh 
of the respiratory tract, but also for eye lesions and intestinal troubles. The 
differential clinical diagnosis of these virus diseases whose causal agents 
can be isolated from the feces and throat washings is still far from precise. 
A clear-cut etiological relationship between any one of the viruses concerned 
and a given respiratory syndrome has been established in only a few cases, 
so that the situation is well described by the phrase "viruses in search of a 
disease. " These viruses are responsible for more or less severe epidemics 
affecting groups of children or adults — particularly members of the Armed 
Forces — in various parts of the world. Usually benign, such infections, 
nevertheless, may prove fatal to children or persons whose resistance is 
low. They are a cause of morbidity and absenteeism and, as such, are 
important from the standpoint of public health. 

The discovery of these viruses in increasing numbers, their wide dis- 
tribution, and the continuing ignorance of their biological properties, degree 
of variability, and stages in their growth cycle, have aroused the interest 
of microbiologists and extended the field of research on respiratory virus 
diseases previously concentrated on influenza. This development is reflect- 
ed in the fact that the WHO Expert Committee on Influenza has now been 
replaced by an Expert Committee on Respiratory Virus Diseases. The follow- 
ing review is made of the first report of this Committee. 

Medical News Letter, Vol. 34, No. 6 99 

Influenza During 1957 - 1958 

Influenza headed the diseases discussed by the experts. The pandemic 
added greatly to knowledge of the disease and Showed the strengths and weak- 
nesses of the world network of epidemiological information and specialized 
laboratories coordinated by WHO. The epidemiological and clinical char- 
acteristics of the pandemic and probable existence of an animal reservoir 
were discussed by the Committee. (A review of these studies was published 
in WHO Chronicle, 13: 163-168, April 1959.) 

Antigenic changes occurring in influenza viruses since 1933 (the year 
when the first of these viruses was isolated) have been generally minor, ex- 
cept in 1946 - 1947 when the Al virus first appeared, and in 1957 when the 
AZ virus — differing more sharply from viruses isolated during previous epi- 
demics than the latter viruses differed among themselves — appeared in the 
Far East. In all probability, this virus will remain the dominant type in 
coming years. The mechanism of antigenic variation, so evident in the type-A 
viruses and less appreciable in the group-B viruses, seems to be based on a 
natural liability coupled with the forces of selection tending to insure survival 
of the virus. It is as though the virus, on encountering an environment which 
is partially immune following previous epidemics, brings into play hitherto 
latent potentialities which enable it to survive for a certain period. Thus, the 
A, Al, and A2 types have succeeded one another during the last 25 years. All 
have a soluble, group -specific antigen in common, but have different virus 
antigens as shown by the hemagglutination test. These differences are some- 
times such that the antibody produced as a response to one virus affords 
hardly any protection against the others as in the case of the Al and A2 viruses. 

The variability of the influenza viruses complicates the problem of vac- 
cination. It might be thought that the inclusion of the largest possible number 
of antigens in the vaccine would insure reasonably reliable protection. How- 
ever, the forces of selection seem to thwart these theoretical precautions and 
the appearance of previously unknown antigens renders them ineffective. 

The role of the World Health Organization Influenza Center is, in part, 
to follow up closely, all over the world, antigenic evolution of influenza viruses 
which remains a major epidemiological mystery. 

Experiments in a number of countries show that vaccination reduces 
the incidence of influenza by two-thirds. To be effective, it should be carried 
out at least 2 weeks before the disease becomes epidemic. The vaccine will 
naturally contain the virus causing the epidemic which, at present, would be 
the A2 virus. It has also been considered advisable to include an Al strain, 
for this virus still may be responsible for certain cases. Some researchers 
have suggested broadening the composition of the vaccine still further by in- 
cluding an A strain, a swine influenza strain, a B strain isolated after 1953, 
and even a Lee 1940 strain. In the light of experience of the last 40 years, the 
antigenic makeup of influenza virus changes to a notable extent only every 10 
or 15 years. Thus, it is probable that vaccines prepared with known strains 
will confer satisfactory protection during the next few years. 

30 Medical News Letter, Vol. 34, No. 6 

There can be no question of vaccinating the whole population. The cost 
would be disproportionate: to its practical value. It is clear that certain groups 
will have priority — those occupying key positions in the general and social 
services and in branches of industry where mass absenteeism would have 
serious economic repercussions. In the event of serious epidemics, age 
groups most threatened also should be vaccinated. 

Vaccination is recommended for expectant mothers and for children 
and adults suffering from diabetes and cardiovascular, renal, or pulmonary 
diseases. During the 1957 pandemic, pneumonia was caused by the influenza 
virus mainly among persons suffering from chronic pulmonary congestion 
following a cardiac complaint, or those in an advanced state of pregnancy. 
Despite its evident pneumotropism, the 1957/1958 virus was relatively mild 
and caused only a low mortality. Nonetheless, it is true that primary pneu- 
monia caused by influenza virus is of major importance and should be antici- 
pated and studied. Cases should be reported immediately to national influenza 

During the last 10 years, a live influenza vaccine has been adminis- 
tered in the USSR with — its advocates report — results as satisfactory as those 
given by the formaldehyde -inactivated vaccine used elsewhere. Researchers 
in the USSR have also advocated serotherapy by the intranasal route using 
hyperimmune horse serum. 

No specific treatment for influenza has been discovered in recent years. 
The Committee mentioned the serious drawbacks which may accompany indis- 
criminate use of antibiotics. Although the latter can save lives in cases of 
bacterial complications — and even in these cases the antibiotics should be 
selected after identification of the responsible microorganisms — they are not 
indicated in cases of uncomplicated influenza occurring in persons normally 
in good health. The dangers of antibiotic resistance which may result from 
such injudicious treatment must not be minimized. 

WHO Influenza Program: Successes and Possibilities for Improvement 

The abundance of data brought together and discussed by the Committee 
is proof of the value of epidemiological services and the network of national 
influenza laboratories operating in liaison with the WHO- sponsored World 
Influenza Center for the Americas. Despite this, the Committee did not 
conceal the shortcomings observed during the recent epidemic. In certain 
countries the dispatch of epidemiological information and virus strains was 
delayed unduly and sometimes neglected despite realization that the epidemic 
was spreading on a large scale and that the new virus was responsible. Nat- 
ional centers for the study of influenza had not been officially designated in 
all countries, not because of any lack of laboratories capable of carrying out 
necessary work of isolation and identification, but owing to lack of organiza- 
tion. Thus, there were regrettable gaps in the network of information and 
of laboratories in relation with WHO which, to be effective, must be worldwide. 

Medical News Letter, Vol. 34, No. 6 31 

The epidemic had already been raging for several weeks before it was re- 
ported. This was because it commenced in ar^as of Asia which do not par- 
ticipate in WHO programs and do not collaborate with epidemiological 
information services. Two months were lost during which arrangements 
could have been made to combat the .epidemic more effectively than, was 
actually found possible. Although it is impossible to foresee the origin of an 
epidemic or what will be its extent and severity, public health measures — 
if taken in time — can, nevertheless, limit its effects. 

Other Respiratory Viruses 

The discovery in 1953, in an adenoid culture, of certain cytologic 
changes caused by a virus until then unknown, opened a new chapter in human 

This and other viruses of the same family were named "adenoviruses" 
after the tissue in which the original virus was found. Since their discovery 
at least 18 serologic types have been isolated. They are found in the res- 
piratory tract from the nose to the lungs, and sometimes on the eye or in 
the intestines. They cause cellular changes in those parts of the organism 
leading to inflammation and hypertrophy of the corresponding lymphatic 
tissues. Fever, pharyngitis, and coughing are the main symptoms to which 
may occasionally be added coryza, lymphadenopathy, headache, and myalgia. 
Some of these viruses also cause follicular conjunctivitis and epidemic kerato- 
conjunctivitis. Spread is favored by communal life. They are often found 
among members of the Armed Forces in the United States and the United 
Kingdom, more often in winter than in summer. They are more uncommon 
among the civil population, but epidemics sometimes arise in child communi- 
ties. Spread is not through air only, but there may be excretion in stools 
over long periods and transmissions as enteric viruses. Occasionally, trans- 
mission has been by water in swimming pools and lakes. 

These viruses form a group with a common soluble antigen. However, 
they can be distinguished from one another by antigenic factors which can be 
differentiated by serologic tests. They have been given the -serial numbers 
1, 2, 3, 4, et cetera. Some types are found more frequently among children, 
others predominate in military camps. 

These viruses grow well only in tissue cultures of human cells, either 
normal or malignant (HeLa, KB for example). Animal tissues are generally 
unsuitable for their culture, although adaptation of certain adenovirus types 
of monkey kidney cell culture has been accomplished with difficulty. A con- 
siderable time may elapse before recovery of the virus is achieved since 
adenoviruses apparently go through a long growth cycle before their presence 
is revealed by cytopathic changes in the cultures. The report includes tech- 
nical details on isolation of these viruses as well as on serologic diagnosis 
by complement -fixation and neutralization tests. 

32 Medical News Letter, Vol. 34, No. 6 

Bivalent or trivalent vaccines containing two or three types of adeno- 
virus have been prepared on monkey-kidney cells and treated with formalde- 
hyde. When administered intramuscularly to members of the Armed Forces — 
particularly liable to infection by adenoviruses — the vaccines led to a decrease 
of 55 to 81% in the incidence of acute respiratory illnesses as a whole and of 
90% in that of diseases caused specifically by adenoviruses. Vaccination is, 
therefore, indicated in barracks and military camps. In 1957 the Federal 
Register of the United States published information on the commercial manu- 
facture of adenovirus vaccine. 

A certain number of viruses have been isolated which cause atypical 
pneumonia and, among children in particular, illnesses sometimes reminis- 
cent of influenza. Examples of such viruses are the Sendai virus of Japan, 
the CA virus (associated with croup), and the hemadsorption viruses HA1 
and 2. (Since the meeting of the Committee, the Virus Subcommittee of the 
International Nomenclature Committee has suggested the inclusion of these 
viruses in a myxovirus para -influenzae group, of which they would be types 
I, 2, and 3; the HA2 virus being attached to type 1. The use of the term 
"influenza D" for Sendai virus should be abandoned.) 

None of the numerous viruses isolated in recent years can be reason- 
ably regarded as the cause of the common cold which remains one of the most 
baffling problems in human virology. 

The report concludes with a series of technical annexes which deal 
with methods for the preparation of sera, typing of influenza strains, tech- 
niques for influenza diagnosis, and the use of complement -fixation in the 
typing of the influenza virus. (WHO Chronicle, 13: 261-264, June 1959) 

£ $ $ $ $ $ 

Penicillin Resistance in Gonococci 

At the end of 1956 it was noticed that a small proportion of male 
patients of the Whitechapel Clinic, The London Hospital, with uncomplicated 
gonococcal urethritis were failing to respond to routine treatment of 300, 000 
units procaine penicillin given intramuscularly, and continued to show gono- 
cocci in their discharges. As reinfection seemed an unlikely explanation, a 
comparison of in vitro sensitivity of gonococci to penicillin with results of 
treatment was undertaken. 

Strains of gonococci isolated from patients — mostly male — attending 
the clinic during April - December 1957 were examined for sensitivity to 
penicillin, using the tube technique. Particular attempts were made to isolate 
strains from treatment failures. Analysis of penicillin sensitivity of 302 
strains of gonococci isolated from patients before any treatment was given 
revealed that 19. 5% were sensitive to a minimal inhibitory concentration of 
penicillin of 0.125 to 0.5 unit/ml. This appreciable proportion of relatively 

Medical News Latter, Vol, 34, No. 6 

resistant strains is in contrast to the findings reported by others between 194 
and 1954, indicating that gonococcal strains are rarely found to be resistant 
to penicillin in concentrations greater than 0.Q6 units /ml. The proportion of 
relatively resistant strains isolated in November and December 1957 had 
increased significantly over that of strains isolated during April and May 1957 
Three of 83 strains of gonococci testedwere resistant to streptomycin at a con- 
centration greater than 1000 meg. /ml. One of these strains was also relative ■ 
ly resistant to penicillin. 

Clinical investigation of the results of treating male acute gonococcal 
urethritis with penicillin began in November 1956 and continued through Dec- 
ember 1957. From a group of 1116 cases treated with an intramuscular 
injection of 300, 000 units of penicillin in oil with 2% aluminum monostearate 
(PAM), or aqueous procaine penicillin, gonococci were found in 124 after treat- 
ment. Sensitivities to penicillin were determined for gonococci isolated from 


251 patients of whom 29 showed post-treatment gonorrhea in the first week. 
Only one of these 29 treatment failure cases gave a history of re-exposure. 
Again, an appreciable proportion (20%) of the 251 strains were resistant to 
penicillin at concentrations below 0. 125 units /ml. Of interest is the observa- 
tion that 21 (72%) of 29 treatment failures were infected with gonococci resis- 
tant to concentrations of penicillin lower than 0. 25 units /ml. It should be noted 
that. only 50 to 60% of the 251 patients were observed for one week or more. 

Patients who were observed with post-treatment gonorrhea gave one of 
the following histories: 

(1) The initial symptoms disappeared within 24 hours of treatment and 
then recurred and persisted after a symptom-free period of one to 2 days. 

(2) The symptoms lessened after treatment, but after a day or two, 
increased in severity up to the pretreatrnent intensity. 

(3) The symptoms remained unchanged or even increased after t ■ 

(4) Occasionally, patients with post-treatment gonorrhea were symp- 
tomless, but a purulent urethral discharge with pyuria was found on exam- 
ination. This apparently asymptomatic carrier state sho\ild be borne in 
mind during the management of gonorrhea, and all patients should be 
carefully examined by stripping the urethra and staining the secretion even 
though most patients may assert that they have recovered. Retreatment 
of these patients consisted of another injection of ^00,000 units of penicillin. 
Most of them were still unimproved and were then treated with 600, 000 
units of penicillin. Again, many of these cases remained unchanged and 
were finally cured by a single intramusculai injection of 1 or ?. gm. of 

Work on penicillin sensitivity of gonococci done in 1946 and 1947 
indicated that the level of penicillin in blood and tissues required to inhibit 
or kill gonococci was 0. 03 to 0. 06 units /ml. This became the standard to 
which penicillin preparations were designed to conform. The authors found 
that blood levels adequate to kill gonococci whose resistance to penicillin 

3 4 Medical News Letter, Vol. 34, No. 6 

in vitro extended to 0. 5 unit/ml. were seldom reached long enough to insure 
good therapeutic results following an injection of 300, 000 units of aqueous 
procaine penicillin or PAM. Examination of blood levels following larger 
doses of penicillin indicated that successful therapeutic results in infections 
with more resistant strains of gonococci can be expected. It was found that 
600, 000 units of benzathine penicillin alone, however, gave worse results 
than 600, 000 units of either PAM or aqueous procaine penicillin. Moreover, 
there may be a real danger that, in using benzathine penicillin with its pro- 
longed duration in blood and tissues, some patients with gonorrhea may be 
converted into living test tubes for producing resistant strains of gonococci. 
It seems that intramuscular injection of 600, 000 to 1, 200, 000 units of aqueous 
procaine penicillin with or without a "booster" dose of crystalline G is likely 
to give best results without undue prolongation of useless and perhaps danger- 
ous levels of penicillin in blood and tissues. It is suggested that efforts be 
made to devise a penicillin preparation which would give a blood level of not 
less than 1. unit/ml. for not less than 24 hours, and preferably for not much 
longer. (Curtis, F. R. , Wilkinson, A. E. , A Comparison of the InVitro Sensi- 
tivity of Gonococci to Penicillin with the Results of Treatment: Brit. J. Ven.Dis., 
34: 70-82, June 1958) 

NOTE: Clinical evidence of increasing resistance of the gonococcus to peni- 
cillin was found in a study conducted in 1958 in Korea. (CAPT E. Epstein (MC) 
USAR, Failure of Penicillin in Treatment of Acute Gonorrhea in American 
Troops in Korea: J. A.M. A., l69r 1055-1059, March 7, 1959) 

"-' -r ».'.- iX* J* -Js -. '<• 

■-,% rf. *■{* rp ?$. rf. 

Essentials of Food Establishment Sanitation 

In the first article of this series (Medical News Letter, 3 July 1959), 
the ir portance of health, health habits, and physical condition of people in the 
food service industry was stressed. Even with present day mechanization, 
the human element in food business is still the number one factor. 

Food Wholesomeness 

Next to people, and practically inseparable in any list of essential 
elements, is food itself. Almost universally, food ordinances stress food 
safety and wholesomeness. However, the question might be raised, "Is too 
much being taken for granted in this phase of the food control program? " 
Although the sanitary quality of food has shown and continues to show marked 
improvement, the sanitarian in his rounds of inspection must be ever alert 
to conditions and circumstances which may endanger food wholesomeness. 

Wholesomeness, as it applies to food, is somewhat difficult to define 
because of the number of points to be considered. Generally, the broad 

Medical News Letter, Vol. 34, No. 6 


meaning of whole someness of food denotes products for human consumption 
that have attributes of purity, safety, and acceptability. Conversely, un- 
wholesomeness i3 easier to define. Here, a long list of detailing conditions 
can be given which directly or indirectly influence food wholesomeness. For 
purposes of this article, wholesomeness will be considered to mean a pure, 
safe, and acceptable product. 

Conditions Affecting Food Wholesomeness 

When food ordinances are viewed as a whole, it is readily seen that 
nearly every provision basically points to protection of food wholesomeness. 
Therefore, the sanitarian must constantly be concerned with a variety of 
conditions which directly affect wholesomeness. Some of the more promi- 
nent circumstances, classified arbitrarily, are: 

1. People and Infectious Materials. Pathogenic organisms may be 
introduced as a result of transmissible illness and carrier state 
among workers. 

2. Water. Food or food containers exposed to, or washed in, 
unsafe water. 

3. Sewage and Plumbing. 

a. Drip from leaking overhead sewer or waste lines 

b. Contamination of food and food containers by sewage 
back flow 

c. Back siphonage into potable water 

d. Flooding of food storage areas 

4. Insects. The house fly and cockroach, when allowed access to 
food, may introduce pathogenic microorganisms. 

5. Rodents. Rats and mice may introduce both extraneous contami- 
nants: i.e., hair, urine, feces, and pathogenic microorganisms, 

6. Storage. 

a. Failure to provide protected storage permitting introduction 
of -foreign materials or harmful microorganisms. 

b. Failure to use cold storage properly, thus allowing undesirable 
change to take place in food. Both enzymatic and bacterial changes 
will result. 

7. Chemicals. Chemicals may be added in a variety of ways, i. e. , 
intentionally or accidentally. They may be in the form of preserv- 
atives or additives, soluble linings or coating on food contact 
surfaces or through improper use of disinfectants, insecticides, 
and rodenticides. 

8. Food Contact Surfaces. Surfaces upon which food is prepared 
or processed and contact surfaces of containers and utensils that 
have not been subjected to effective bactericidal treatment may 
contribute to food unwhole someness. 

9. Improper Cooking. Aside from a number of infectious bacteria, 

36 Medical News Letter, Vol. 34, No. 6 

parasites and helminths also may remain viable if cooking is not 
complete. Trichinosis from insufficiently cooked pork, and botulism, 
which may result from ingestion of improperly processed canned 
food, are classic examples. 

10. Food Inherently Poisonous. These include mussels and clams in 
certain seasons, poisonous mushrooms, flesh of certain fish, and 
ergotism from parasitic fungus of rye grain. Food allergies also may 
be mentioned as a factor. 

Checking fur Signs of Unwholesomeness 

The ten foregoing items point to the need for diligence in the inspection 
of food served to the public. ETiistence of any one or a combination of the el- 
ements listed can constitute the cause of illness. Sufficient epidemiological 
studies of foodborne outbreaks have been made to confirm that, somewhere 
along the line, some safeguard has been neglected and food has become un- 

Aside from the usual environmental survey of the food establishment, 
made routinely by public health and other personnel, there are other signs 
and criteria which the sanitarian can use to evaluate food whole someness. 
Some of these criteria will be given for specific foods. They mainly apply 
to organoleptic appraisal and are useful in making on-the-spot decisions either 
to condemn food as definitely unwholesome or to order it withheld from sale 
until more exacting laboratory determinations can be made. 

Some Signs of Unwholesomeness 
Fresh Meat 
i. Beef 

a. Slime is the result of bacterial growth and is evidence of lack of 
proper temperature and moisture control in the refrigerator. Slime is 
usually noticed first on those parts where circulation of air is most re- 
stricted—underneath skirt and hanging tenderloin and on the inside of the 
flank. Slime is evidenced by moist, sticky surfaces accompanied by a 
distinct odor which in advanced cases may become offensive. If this 
condition is found to be extensive, beef should be rejected because it 
indicates faulty handling. The seriousness of surface slime lies in the 
fact that internal deterioration may have taken place. 

b. Evidence of Contamination. If beef quarters or other wholesale 
cuts are found to be soiled and dirty there is indication of carelessness 
during transportation and delivery. This calls for investigation of hand- 
ling methods used by the packer or wholesaler. Beef, either fresh or 
frozen, never should be piled on a dirty floor. Beef that becomes wet 

or contaminated with dirt spoils more readily than dry clean beef. Clean- 
liness of the beef carcass is highly important. Trucks used for transport- 
ing fresh meat should be scrupulously clean, and the floors should be 
covered with clean paper or canvas. All trucks should be covered. For 

Medical News Letter, Vol. 34, No. 6 37 

long hauls refrigerated trucks are used, but for local delivery, generally 
they are not. In hot weather, even for local delivery, refrigerated trucks 
should be used because of the high perishability of the product. 

c. Detection of Sulphite, Sodium sulphite is sometimes illegally 
added to hamburger to conceal inferiority and give meat a fresh red appear- 
ance. Such adulteration can be detected through the use of malachite green. 
Ten drops of a 0. 20% aqueous solution of malachite green is added to one- 
half teaspoonful of meat. Meat containing sulphite will decolorize the dye 
quickly. This is a useful field test for detection of added sulphite. 

2. Fresh Fish 

Signs of Spoilage. Fresh fish is very perishable. The condition of 
fresh raw fish can be judged by noting certain points. The gills should be 
pink to dark red in color and firm. As decomposition takes place the gills 
become slimy and gray or grayish green. In stale fish, the eyes become 
dull and sunken. When decomposed blood cells diffuse into the flesh, a 
reddish color around the backbone is noted. A stale fish laid across the 
hand is less rigid than a fresh one. In stale fish the flesh will pit on 
pressure because resiliency has been lost. 

3. Oysters 

Signs of Spoilage. Aside from organoleptic testing, a pH reading on 
oysters or oyster liquor will assist in establishing wholesomeness. The 
pH of fresh shucked oysters varies between 6. and 7. 0. A pH value of 
5. 4 to 5. 8 is regarded with suspicion. Values below this range are indi- 
cations of decomposition. Convenient field examination can be made of 
the liquor by adding methyl red indicator solution. This indicator has a 
range of pH 5. 4 to 6. 0. 

4. Poultry 

Signs of Spoilage. Dressed poultry decomposition can be detected 
by a stickiness under the wings, under the thighs, at the top of the wings, 
and around the apron. There is a sebaceous gland at the latter portion 
that is often cut out by the dresser because of its quick spoilage detecting 
property. Chilled chickens, both drawn and undrawn, have limited 
keeping qualities. In undrawn birds, the contents of the digestive tract 
are likely to ferment unless temperatures close to freezing are maintained. 

5. Other Foods 

a. Stored cereals should be examined for possible insect infestation, 
rodent contamination, discoloration of sacks indicative of overhead leakage, 
and moldiness. 

b. Canned foods should be examined for leakers, springers, or 
swells. A leaker is a can not hermetically sealed and which allows air 
to enter and the product to exude. Leaks are qualified by section of can 
affected such as crimp, seam, end, or body. Springers are filled cans 
with ends which are bulged. This may be from over filling, insufficient 
exhausting, production of hydrogen or carbon dioxide gas through bacterial 

38 Medical News Letter, Vol. 34, No. 6 

action, or action of acid content on the metal can. When one end is 
pressed in with the hand or fingers, the opposite end will bulge out. 
Products in such cans are not safe for consumption and should be re- 
jected. Swells are bulged out filled cans with both ends remaining taut 
as distinguished from the springer. Swells are caused by much the same 
condition as springers. The swell may also be due to pin point leaks 
which allow entrance of micro-organisms. Swells should be rejected. 

Exercise of Powers of Observation 

This article does not list all of the many defects which may occur 
in food. However, the examples which are. given indicate that the sanitarian 
should look at food with a trained eye. Observation of processing, transpor- 
tation, preparation, and storage may reveal faults which lead to some of the 
conditions described in the foregoing. Most food defects indicate faulty 
handling or a failure to employ satisfactory techniques. Persons working 
regularly with foods should cultivate an inquisitive attitude toward food 
wholesomeness. This is essential to the proper enforcement of a provision 
which is common to most food ordinances; namely, "All food and drink shall 
be wholesome, free of spoilage, adulteration, misbranding, and contamination 
and shall be safe for human consumption. It shall be prepared and served in 
a sanitary manner under sanitary conditions. n Essentially, this provision 
constitutes one of the basic principles for effective food control. Other 
specific details establishing environmental factors stem from it and are 
closely allied with it. (Special Service Article — Some Essentials of Food 
Establishment Sanitation : J. Milk and Food Technology, 22: 82-84, 
March 1959) 

Salmonella Blockley Outbreak 

Two cases of suspected paratyphoid fever were reported from a Long 
Beach naval facility. After questioning these patients, the Medical Officers 
were led to believe that a food infection was involved and that the suspect 
food had been served at a wedding reception. This fact was immediately 
reported to the health department. Had this not been done it is quite likely 
that this particular food infection episode would never have been known as 
such. ' The sailors were unable to recall where the wedding reception had 
been held, but they stated that information about the reception could be ob- 
tained from persons frequenting a certain bar in the city of Los Angeles. 

Surprisingly enough, when the bar was contacted it was found that 
persons who attended the wedding reception were known as frequent patrons 
and that it would be possible to reach them at that address. Through the 
cooperation of the Los Angeles City Health Department an inspector visited 

Medical News Letter, Vol. 34, No. 6 


the bar and was able to obtain a list of 70 names and addresses of guests at 
the reception. Victims were found to reside not only in the Los Angeles 
County Health Department area but also in Long Beach, Los Angeles City, 
and Hanford in Kings County. Subsequent investigations indicated that 31 
of the 70 persons were ill following the reception. Salmonellae were iso- 
lated from 10 of the specimens submitted by the 31 victims. The salmonella 
organism was subsequently identified as Salmonella blockley in the laboratory 
of the State Department of Public Health. 

This was a new species of salmonella in Los Angeles County. Infor- 
mation furnished by the State Department of Public Health showed that Salmo- 
nella blockley was isolated in California once in 195 7 and 3 times in 1958. It 
was first identified in 1954 in eastern United States where outbreaks involving 
several thousand persons were traced to chicken. 

Since 1 January 1959, California has experienced two outbreaks 
involving Salmonella blockley— one in the San Francisco Bay area and the 
other, described above, in Los Angeles county. The Bay area outbreak in- 
volved seven different dinner parties at one restaurant on New Year's Eve. 
Shrimp cocktail or chicken was the suspected food. Chicken appears to be 
definitely involved in the Los Angeles outbreak as there were victims in two 
households who did not attend the wedding reception but ate chicken which was 
brought from the reception. The method of preparation and handling of the 
chicken prior to and during the wedding reception was such as to be conducive 
to maintenance and spread of the infectious agent in the food. (Carson, C. C. „ 
Introducing Salmonella Block-ley, One of Los Angeles County's Newcomers: 
Los Angeles County Health Index, Z0 June 1959) 

Calcium Hypochlorite 

An unusual incident was reported in the Preventive Medicine Report 
of an Air Force base. In the process of adding calcium hypochlorite to the 
automatic chlorinator at the swimming pool, a paper cup was used as the 
container for the chemical rather than the hard rubber or plastic cup normally 
employed for this purpose. The airman involved had filled the paper cup with 
calcium hypochlorite and was holding it when the cup began to glow and then 
burst into flames. 

In the excitement produced by this unexpected reaction, the flaming 
cup was inadvertently dropped into a nearby 100 -pound drum of calcium hypo- 
chlorite, resulting in a fire and explosion, and toxic fumes were liberated 
from the burning material. Two men were burned and one suffered tempo- 
rarily from the inhalation of chlorine gas. None of the injuries was serious. 

After several experiments to determine the cause of this accident,, 
some facts were determined. By adding slight amounts of coffee, cream, 


Medical News Letter, Vol. 34, No. 6 

and sugar to calcium hypochlorite, a fire and small explosion could be pro- 
duced. This phenomenon seemed to take place only when some sort of 
moisture and sugar were present together. Similar results could not be 
produced when the cup contained sugar, water, or cream alone. 

Although the reason for this accident may not be entirely clear, it 
is obvious that similar mishaps can be avoided if only clean cups made of 
hard rubber or plastic are used when dealing with calcium hypochlorite. 
(Safety Review, 16:5, July 1959) 

NOTE: Medical Department personnel should be familiar with the precautions 
contained in United States Navy Safety Precautions, OPNAV 34P1, concerning 
the handling of calcium hypochlorite. 

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